Elements and Settings of Care The Palliative Response

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Elements and Settings of Care The Palliative
Response
F. Amos Bailey, M.D.
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Palliative Care
Inpatient Palliative Care Units
Consultation
Home
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Palliative Care Time Line
Therapy with Curative Intent
Hospice
Bereavement Care
Palliative Care
6m Death
Symptom Rx Supportive Care
Presentation
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Elements
Acute Palliative Care Unit Skilled
Unit Residential Hospice
Home Hospice Home Health Nursing Home
Hospital Consultation Ambulatory
Outpatient Home
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Continuity of Care Last Year of Life of John,
Age 83

• Home - Lived alone in apartment
• Brought to ER
• Admitted to General Medical Service (Progressive
  Stage D Prostate Cancer)
• Transferred to Palliative Care Unit
• Discharged Home when stabilized
• Home Hospice
• Supportive Care Team from his church

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... Johns story continues

• Readmitted to Palliative Care Unit 2 months
  later
• Discharged to Nursing Home - Hospice Care
• Good pain control
• Friends and church members visit
• Pain worsens as progression of illness interferes
  with taking medication
• Readmitted to Palliative Care Unit
• Symptoms aggressively managed
• John dies 10 days later

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Johns End-of-Life Care A Schematic of Required
Settings
Home
Congregational Care Team
Inpatient Palliative Care Unit
General Medicine Service
Home Hospice
Nursing Home with Hospice
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Settings of Care
Home Home Health Medicaid Waiver PACE Home
Hospice
Residential Assisted Living Boarding
Home Nursing Home Residential Hospice
Hospital Emergency Ward ICU Medical
Wards Inpatient Palliative Care Unit
Deaths in USA 23 Home 24 Nursing
Homes 53 Hospitals
Teno et. al., 1997
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Assessment of Needs

• Where did people die in your health care system
  last month? Last year?
• What were the problems with the care of the dying
  in your system?
• Poorly controlled symptoms
• Overwhelmed families and patients
• Crisis to crisis
• Lack of preparation and frequent surprises
• Resources depleted
• Emotional and spiritual isolation

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Inventory of Strengths and Resources
Facility Space Administrative willingness Financi
al resources
Personnel Physician Nurse Social
Worker Chaplain Competency? Interest ?
Time ?
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Valued Added to Patient/Families

• Suffering addressed
• Relief of suffering
• Increased capacity to bear suffering
• Issues of meaning addressed
• Assistance to find meaning and purpose
• in the face of illness

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Value Added to Staff and Institutions

• Improved patient and family satisfaction
• Effective resource utilization
• Improved staff morale
• Disposition for patients in need
• Improved quality of care through
• development of expertise throughout the
  institution

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Value Added for Hospice

• Increase in referrals
• Earlier referrals
• Less crisis intervention
• Continuity of care
• Safety net in an inpatient setting if home
  management is not possible

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Choosing a Model of Care

• Begin with a program
• that matches need with available resources
• Hospital Consultation
• Inpatient Unit
• Ambulatory Clinic
• Nursing Home
• Home Health

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Matching Need and ResourcesElements
Home Hospice
Palliative Care Nurse Consults in skilled
unit and nursing home Assesses patient
appropriateness for hospice Coordinates care
of hospice patients transferred into hospital or
nursing home
Home Health
Skilled Unit
Nursing Home
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Matching Need and Resources Elements
Home Hospice
Home
Physician Begins Palliative Medicine Consult
Service in acute care hospital and clinic Service
results in improved symptom management and more
referrals to hospice
Ambulatory Outpatient
Hospital Consultation
Skilled Unit
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Matching Need and ResourcesElements
Acute Palliative Care Unit
Home Hospice
Hospital Consultation
Skilled Unit
Home
Hospitals and Hospice Open Palliative Care Unit
with hospital consultation to provide better
palliative care to patients
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Matching Need and ResourcesElements
Home Hospice
Local Hospice Opens residential unit to provide
inpatient hospice care for patients cared for at
home, in nursing homes or in acute care hospital
Home Health
Skilled Unit
Nursing Home
Residential Hospice
Home
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Self Care for the PhysicianDealing with
Lifes End

• F. Amos Bailey, M.D.

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Rx for Self CareUnderstand Grief and Loss

• Physician Grief is Inevitable
• Physicians care for many patients
• at Lifes End

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Rx for Self CareUnderstand Grief and Loss

• Physician Grief is Natural
• Feelings of grief are the natural response
• to loss and the tragedies that can occur
• at Lifes End

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Rx for Self CareUnderstand Grief and Loss

• Physician Grief Deserves Attention
• Develop healthy responses
• to grief and loss

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Rx for Self CareRespect Burn-Out

• Burn-out can occur in any field
• Fatigue
• Losses
• Unresolved emotional distress
• May be more common
• in the emotionally charged setting
• of End-of-Life care

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Rx for Self CareMutually Supportive Team

• Value of Interdisciplinary Team
• Recognizes unique strengths and abilities
  accepts individual limits
• Fosters requesting and providing assistance
  relieves provider from bearing loss alone
• Understands grief as normal and expected
• Gives medical providers permission to experience
  feelings of grief and loss
• Provides forum to resolve inevitable conflicts

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Rx for Self Care Re-Frame Clinical Success

• Focus on Healing vs. Cure
• at Lifes End
• Focus on Success in Healing
• vs.
• Failure to Cure

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Clinical Success at Lifes End

• Fostering holistic healing
• Enabling patients to live life fully
• Providing good symptom control
• Supporting patients and families

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Rx for Self CareSelf-Monitor Physician Stress

• Ask
• Do I still enjoy my work?
• Are there patients or tasks that I avoid or
  dread?
• Do I attend to my personal health?

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Rx for Self Care R R

• Recuperate
• Make time for adequate rest and sleep
• Restore
• Take time for meals and breaks
• Eat nutritiously
• Enjoy coffee and tea in moderation
• Stay well hydrated

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Rx for Self CareR R

• Rejuvenate
• Regular exercise is good for body and soul
• Refer
• If concerned about your health, take time to see
  your own doctor

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Rx for Self CareR R

• Relaxation
• Take regular time off
• Take all annual vacation time every year
• Recreation
• Develop interests and creative outlets right for
  you at this time in your life
• (e.g., gardening, reading, travel, music)

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Rx for Self CareR R

• Relationships/Personal
• Take time for family and friends
• Make memories and leave legacies daily
• Formal and informal support groups
• Relationships/Professional
• Seek mentors and be a mentor
• Valuable to even the most skilled medical
  provider
• Discuss problems/feelings identify new solutions

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Rx for Self-CareR R

• Self-Refer for Emotional Health
• If concerned about depression, discuss with your
  health care provider
• Self-Refer for Substance Abuse
• Monitor self for abusive behaviors with
  substances and take action if concerned

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Rx for Self Care

• Develop a
• Sense of the Transcendent

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Rx for Self Care R R

• Reflection/Religion or Philosophy
• Maintain/strengthen your faith tradition
• Read or study in religion or philosophy
• Reflection/Personal
• Keep a personal journal
• Engage in a reflective practice (e.g., mediation,
  Yoga)

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RxPhysician, Heal Thyself

• Self care is an important part
• of being a mature and effective
• health care provider

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Rx for Self CareR R

• Dying personseven dying physiciansseldom say,
• I wish I had spent more time at work